Does Universal Health Coverage promote antibiotic resistance?
Background: Antibiotic resistance has been declared a public health emergency (ref) while at the same time access to essential health care as part of UHC has become a global target (ref). Zanzibar’s health policy states that an essential health care package should be provided free of charge to all Zanzibaris. Treatment guidelines for children under five years of age (Integrated Management of Childhood Illness (IMCI)) and for adults (Standard Treatment Guidelines) are available in all health facilities. A‘basket fund’ provides adequate funding to all of Zanzibar’s ten Health Districts to monitor their use by health providers. Primary Health Care facilities are staffed by clinical officers and/or nurses with support from ‘orderlies’ (untrained cleaners). Most primary health care units have at least one staff member training in the use of the IMCI guideline. In July 2013, the Ministry of Healthintroduced Performance-Based Financing (PBF) in two Health Districts. One of the indicators selected in this pilot reform was ‘treatment according to treatment guidelines’. The Ministry conducted verification exercises quarterly in the pilot Districts.
Key findings: Within the first six months of implementation treatment provided in accordance to the available guidelines increased from, on average, 24% to 85% (Hadley & Beard 2019). As a consequence of the improved adherence, antibiotics given ‘not according to guidelines’ fell from 49% to 4% of all prescriptions compared with 40% to 29% in the non-pilot districts during thepilot period of three years.
Policy Implications: In pursuit of increasing access to basic curative health services in the absence of a close monitoring system, such as direct quality indicators in PBF, it is likely that an increased number of patients would be prescribed an antibiotic that is not recommended by the existing treatment guidelines. So while increasing access to curative consultations in the pursuit of UHC, ignoring the local context could simultaneously negatively impact efforts to curb global antibiotic resistance.
